4. Section(s) of Criminal Code for offences for which disposition or placement decision made

5. Disposition or placement decision appealed from

6. Length of hearing

7. Date of disposition or placement decision1

8. If accused in custody or detention, place of incarceration or detention

9. The verdict at trial2

TAKE NOTICE that the accused applies for an extension of time within which to launch the within appeal upon the following grounds: (here state reasons for delay)

TAKE NOTICE that [identify party appealing] appeals against the disposition [or placement decision] upon grounds involving a question of law alone or fact alone or mixed law and fact.

The grounds of appeal are:

The relief sought is:

The appellant’s address for service is:

Dated this day of 19

(Name, address and telephone number of appellant’s solicitor or (where none) the appellant)

To: the Registrar

Numbered notes set out below refer to corresponding numbers on notice

Note 1. This notice of appeal must be served within fifteen days after the day on which the parties are provided with a copy of the disposition or placement decision and the reasons for it, by delivering a copy of the notice of appeal to the person in charge of the hospital or other institution in which the accused is in custody or by delivering to the office of the Registrar or by mailing to the Registrar by registered mail three copies of the notice of appeal, and, in addition, in an appeal by the Attorney General or by a party other than the accused, by personal service on the accused. If the accused is the appellant and is not represented by a solicitor then he or she must indicate in the space provided the reasons for failing to serve the notice of appeal within the time limit.

Note 2. That is, whether the verdict was that the accused was unfit to stand trial or not criminally responsible on account of mental disorder.